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Elderly HomelessMen and Women: Aged Care’s Forgotten People
Bryan Lipmann, AM
Chief Executive Officer, Wintringham, 136 Mt Alexander Road, Flemington
PO Box 193, Flemington, Victoria 3031
Tel: 03 9376 1122; mobile: 04 1188 5750; Fax: 03 9376 8138
Email:
Abstract
In spite of Australiahaving an aged-care system that provides a wide range of residential and community-based,aged-care services to elderly men and women, which are appropriately monitored and audited, homeless people have historically found it difficult or impossible to access those services. It remains an appalling blight on the aged-care industry in general, and the social work profession in particular, that this apparent selective exclusion of the most vulnerable of elderly people should continue with little or no comment, criticism, or action.
This is a policy commentary rather than an academic research paper, and aims to alert readers to the plight of elderly homeless people. The paper provides some insight into the life of an elderly homeless person, it describes the interaction between elderly homeless people and the Aged Care System; discusses services provided by Wintringham, a welfare company specialising in providing aged-care and housing services toaged homeless people; and explores some of the policy responses suggested by Wintringham.
The Homeless Elderly Population: The Problem Identified
Homelessness is the end result of a social system in decline.Night shelters, with their large resident populations of physically, psychiatrically, and intellectually disabled people who havelittle or no external supports, living beside desperate, lonely, and at times, violent young men, are a public manifestation of that chaotic decline (Lipmann, 2006).[1]
Nobody can work with elderly homeless people without feeling overwhelmed at times. The degrading conditions in which many live and the constant violence to which such circumstances give rise, together with the lack of resources to meet the seemingly endless crises that have to be met, makes even the most optimistic worker feel, on some days, that it is all futile. The large night shelters in Melbourne have now all closed, although many frail and elderly homeless people continue to live in private boarding and rooming houses, where conditions, if anything, are worse than the shelters. Shelters still exist in other Australian states and certainly in most large cities around the world. While many cater to large numbers of people, a typical night shelter provides dormitory accommodation for about 200 men each night in rooms where up to 50 men will sleep. In New York, the most current estimates place 34,776 people in the shelter system (Kolker, 2008). Of course, this figure bears no resemblance to the actual numbers of homeless people, which is many times larger than the number of people seeking shelter accommodation. For example, in Australiathe 2006 Census estimated that over 110,000 people were homeless on any given night.
For the average person in the community, the concept of homelessness is vague at best or, if pressed, entirely unimaginable from a personal or family perspective. To live on the streets, to scavenge for food, to be sick and unable to get care, to be subject to bashings and random terror of gangs, police, or from other homeless people, is simply unimaginable. As difficult as it is for the public to contemplate what life must be like if they were homeless, few could begin to imagine what it must be like if the homeless person was the age of their parent or grandparent.Yet elderly and frail men and women make up a significant number of homeless people;in fact, surveys of night-shelter populations in the 1980s suggested that up to a half of all residents were older aged, a figure that can only have increased over time. In Australia in 1985, the Federal Department of Housing and Construction estimated that 40,000 people slept outdoors and 60,000 people were housed inadequately, many of whom utilised the night-shelter system (Coopers and Lybrand & Scott, 1985).
To cope with life in a night shelter requires coping skills that many frail-aged people either do not possess or are unwilling to risk. However, the alternativecan be even more dangerous. While Australian winters are relatively benign compared with those experienced in North America or Europe, frequently it is not just hypothermia that threatens homeless people; it is violence from other street dwellers that presents the most risk (Ballintyne, 1999).
Jeff was a homeless old man living at Gordon House in Melbourne in the 1980’s. His incoherent ramblings and regular verbal outbursts, while annoying to many of the residents, was generally tolerated by most of the people who had lived at the Gordon any length of time.
A combination of his refusal to accept any form of treatment or help, and a complete failing of the public health system to assist staff at Gordon House, meant that Jeff wandered the building ranting to himself and occasionally to others.
Jeff was found one afternoon on the 3rd floor of the building, being held down by three men while a young woman bashed him. He had annoyed the wrong people.
The stories of the brutal conditions that elderly homeless men and women endure are numerous. Anyone who has worked with homeless people can describe violent and frequently fatal attacks that largely go unreported and un-investigated.This remains one of the most tragic and inexcusable faults of our society that, at a time of their life when they are most vulnerable, elderly and frail homeless men and women can expect little or no support, sympathy, or services.
The catalyst that drives many of these men and women into night shelters is usually the loss of their housing. In arecent international study, two-thirds of a newly homeless older population had never been homeless before. The primary antecedent cause was thattheir accommodation had been sold or wasin disrepair, their rent in arrears, the death of a close relative, relationship breakdown, and disputes with other tenants and neighbours. Contributing factors included physical and mental health problems, alcohol abuse, and gambling problems (Crane et al., 2005). The fact is, few elderly residents of night shelters ever “get lucky” and leave for better accommodation.
Sometimes, an appearance of independence only masks intellectual or psychological disabilities. At times, an apparent complete withdrawal from mainstream society and a reluctance to accept any assistance has dramatic consequences.
Some years ago, on a cold and wet Melbourne winter’s night, an elderly homeless man was brought into the shelter I was working at. A young couple had been driving past an inner suburban park and had happened to notice the old man standing near a tree in the rain. Although he refused their help, he nevertheless was somehow bundled into their car, and delivered to the shelter. The couple then drove off, apparently satisfied with their Good Samaritan deed.
The old man was clearly distraught and trying to calm him, I gave him a chair and squatted on the floor beside him. He wouldn’t (or couldn’t) talk, and refused the offer of food or a bed for the night. His clothes were torn and in spite of being many layered, threadbare. My eyes happened to fall on his legs and there I saw what once must have been a horrible wound on his leg. His sock disappeared into the wound that was now covered with an angry scar, only to reappear some inches later.
He obviously had not received any dressings for the wound, or changed his socks during the long process of healing. What horrors lay under the skin could only be imagined.
I stood up and went off to call someone to get a nurse or doctor to the shelter. When I returned a minute or so later, the man had disappeared and gone back into the night. We never saw him again.(Lipmann, 2007)
As horrific as this story is, it represents a fairly common experience for people who work with homeless older people. Whether it is a product of a sense of maleness that one should stoically bear illness or ailments, or whether it has been learned by experiencing rude and dismissive hospital staff, reluctant to work with homeless people, the effect is the same. Older men, and to a lesser extent older women, often refuse to go to hospital, saying that is where you die. Inevitably, they wait so long that when they are eventually admitted it is to an emergency ward where their prophecy often becomes self-fulfilling.
The fierce independence of many of elderly homeless people is a significant reason why they receive so few services. It is not as if workers in homeless services exclude elderly people or deliberately target younger clients. In fact, it is invariably the reverse: many workers feel great sympathy and concern for older people who are homeless. Rather, the problem is one of an overwhelming presence of younger homeless people demanding time and resources; the reality is, workers rarely have time to search out the lonely and isolated members of society, and succumb to a reactive process of dealing with immediate problems. Therefore, elderly homeless people who remain independent and reluctant to seek out services, and whoare rarely assertive about their rights in the ways that younger homeless people can and rightly do, become lost to the system. Older homeless people have been described as “feral” in that they become almost invisible to the rest of the community, learning through hard experience that it is often safer and wiser to withdraw and not draw attention to themselves (Lipmann, 2007).
Before any relationship with an older homeless person can begin, the person needs to feel thathe or she can trust you. Relationships start over a shared smoke, a footy story, or a joke about someone else. Only later is it sometimes possible to begin to tackle housing or health issues.Faced with the daily problem of trying to meet just a few of the vast needs that are continually presented to them, workers in homeless services often do not have this level of spare time to engage with elderly people. Trying to “make do” in often the most trying of conditions, many workers are similar to homeless people themselves, lurching from crisis to crisis.But, should it be the responsibility of workers in homeless services to take care of the elderly population? Is it reasonable to expect a homeless service system to be able to respond to the needs of aged and frail homeless people?
The Homeless Elderly Population and the Aged-care System
It has been a well-accepted fact for many years that Australia, in common with most other western countries, has a disturbingly large number of elderly people living in poverty.The 2006 Census estimated that 42% of the Australian homeless population was over the age of 35 years (n = 44,300) and, in this group, men outnumbered women by approximately 3 to 2 (Chamberlain & MacKenzie, 2008).What has not been commonly accepted is that manyof the impoverished and marginalised elderly men and women became homeless. To the extent that “homelessness” is taught in social work courses,elderly homeless people rate barely a mention. Certainly, in the 1980s, there was no mention of people who were aged and homeless.The result of the profession most charged with responsibility for looking after the elderly homeless population not acknowledging their existence, has been that at a time in their lives when these elderly people most need assistance, they have been left to fend for themselves.The consequences of this lack of interest have been many and varied.
A primary concern is that elderly homeless peoplehave not readily been assigned to a policy environment where their needs can be addressed in a structural and consistent way. While a few individual organisations working with the elderly homeless population, such as Wintringham, have had success in alerting the decision makers in Canberra to this policy vacuum, it can hardly be said that the industry as a whole is concerned with the needs of aged homeless men or women. Consequently, few social work students are graduating with “a fire in their belly” to change the living conditions of elderly homeless people.Thisabsence of a clear policy environment has meant that aged-care organisations, which are themselves frequently managed by social workers, can overlook the needs of the aged homeless population and concentrate instead on the more lucrative market of mainstream demand. The fact that the Government has allowed this highly selective rationing of scarce aged-care dollars to continue is only slightly less scandalous than the policies of the not-for-profit aged-care providers who adopt such policies.
With the door to aged-care services effectively closed to the elderly homeless population, remaining options are indeed bleak. The most common outcome is premature death – often in the most appalling circumstances. Before death comes, a variety of frightening and totally inappropriate accommodation options are available, including government funded not-for-profit homeless services, substandard rooming or boarding houses (some so violent that outreach workers will only enter in pairs or with police escort), or rooms above hotels, euphemistically known as pub tops.
We should read again the Universal Declaration of Human Rights. Many of the Articles are relevant to the homeless population but particularly Article 1 (“All human beings are born free andequal in dignity and rights…”) and, in the case of the elderly homeless population, Article 25 (“Everyone has the right to …. security in old age or circumstances beyond his control”) (World Health Organization, 1948).It is not hard to see how elderly homeless people end up in such circumstances, given what appears to be the prevailing view of graduates of both nursing and social work, namely, that elderly homeless people have no special claim to aged-care services. How else to explain the extraordinary difficulty that our workers face daily in trying to access health or aged-care services for their aged clients? With some notable exceptions, there are a wide range of “gatekeepers”who appear intent on making it as difficult as possible for homeless people to access mainstream services.
Interestingly, a study tour in 1993 confirmed that what was happening in Australia was, to a significant degree, being replicated in Sweden, Denmark, United Kingdom, and the United States (Lipmann, 1995).The extent of this selective rationing of resources is nothing new. In the early 1980s, while working at Gordon House, then the largest homeless persons’ night shelter in Australia, I saw how hard it was to get elderly homeless men and women living in shelters into aged-care programs.Gordon House was a 300-bed building that provided temporary accommodation to men and women from every conceivable background, from Chilean refugees who had been tortured in their homeland and then abandoned when they reached Australia, to intellectually-disabled men on remand, to young women with drug addictions, to violent and seriously disturbed men. The other group of people who made a profound impression on me was the large number of elderly men and women who were living more or less permanently at Gordon House.It would appear that for many professionally-trained people, the existence of large numbers of elderly impoverished people in a homeless night shelter was not a major concern; nor was it a matter that troubled their interpretation of what their profession stood for. It is difficult to come to any other conclusion, given the extreme difficulty that workers at Gordon House faced in accessing either appropriate medical treatment or aged-care services for their clients?
My own epiphany about the injustice of elderly people living in a night shelter came about through a series of events involving some of our clients.
One Friday night before leaving Gordon House, I helped our community nurse take two men to the PrinceHenryHospital, both of whom were suspected of having heart problems. At the hospital we became involved in a lengthy argument with the Triage who at first refused to take the men and then only extremely reluctantly agreed that they should at least be checked.
After leaving them at the hospital, my wife and I took my parents to a performance of Circus Oz. Coincidentally, during the performance, my father had a heart attack. We managed to get him out of the circus tent, into a taxi and then to St Vincent’s Hospital. He stayed at St Vincent’s for about 10 days where they performed all manner of tests while he recuperated in the private patient section of the hospital. Dad went on to live for another 9 years.
When I returned to work on Monday morning, I was told that the two homeless men I took to Prince Henry’s had both been discharged from the hospital about an hour after I took them in, and were both found dead in the shelter the next morning. One of the men in particular had died a terrible death. He was found in the morning jammed between the bed and the wall in a tangle of sheets, faeces and urine as he hopelessly struggled to his death.